A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

Encourage fluid intake of 2.5 L per day.

Assist the client to cough and deep breathe every 4 hr.

Encourage independence in completing ADLs.

Use an N-95 respirator when providing client care.

Answer and Explanation

The Correct Answer is A

A. Encourage fluid intake of 2.5 L per day.

This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.

B. Assist the client to cough and deep breathe every 4 hr.

This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.

C. Encourage independence in completing ADLs.

While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.

D. Use an N-95 respirator when providing client care.

This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.

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Correct Answer is A

Explanation

A. Lower oxygen saturations of 93% to 94%

In an older adult client with a pneumothorax, the nurse could expect to observe lower oxygen saturations of 93% to 94%. A pneumothorax involves the accumulation of air in the pleural space, which can compress the lung and impair gas exchange, leading to hypoxemia (low blood oxygen levels). Decreased oxygen saturations would be a common finding in this condition.

B. Higher oxygen saturations of 98% to 99%

Higher oxygen saturations would be less likely in a client with a pneumothorax due to impaired gas exchange resulting from lung compression. Oxygen saturations are more likely to be lower in this condition, as indicated in option A.

C. Lower energy expenditure

While a pneumothorax may cause discomfort and dyspnea, which could potentially decrease energy expenditure due to reduced activity levels, it is not a direct physiological effect of the condition. Energy expenditure would depend on various factors, including the severity of symptoms and the individual's overall health status.

D. Increased lung capacity

A pneumothorax typically results in a decrease in lung capacity rather than an increase. The accumulation of air in the pleural space causes partial or complete collapse of the affected lung, reducing its ability to expand and decreasing overall lung capacity. Therefore, increased lung capacity would not be expected in a client with a pneumothorax.

A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

Correct Answer is B

Explanation

A. Metabolic acidosis

Metabolic acidosis is characterized by a low pH (< 7.35) and a decreased bicarbonate level (< 22 mEq/L). In this scenario, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not support a diagnosis of metabolic acidosis.

B. Respiratory acidosis

Respiratory acidosis occurs when there is an accumulation of carbon dioxide (PaCO2 > 45 mm Hg), leading to a decrease in pH (< 7.35). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), consistent with respiratory acidosis.

C. Metabolic alkalosis

Metabolic alkalosis is characterized by a high pH (> 7.45) and an elevated bicarbonate level (> 26 mEq/L). In this scenario, the pH is low (7.22), and the bicarbonate level is also elevated (28 mEq/L), which does not support a diagnosis of metabolic alkalosis.

D. Respiratory alkalosis

Respiratory alkalosis occurs when there is a decrease in carbon dioxide (PaCO2 < 35 mm Hg), leading to an increase in pH (> 7.45). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), which is not consistent with respiratory alkalosis.

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A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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